Psychological Treatments of SZ

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Token Economy

Token Economy (TE) is based on behavioural therapy, which argues that all behaviour is learned and that schizophrenia is simply an example of the wrong learning (Maladaptive Learning)- therefore, it views schizophrenia as the result of conditioning. It focuses on the person's current problems and tries to change the unwanted behaviour (known as behaviour modification) through OPERANT CONDITIONING. 

Token economy (TE) is known as behaviour modification and is based on operant conditioning, which is learning from the consequences of actions. It is based on operant conditioning beause it involves selective positive reinforcement or reward. In the first stage of treatment, schizophrenic patients are rewarded for not showing any behaviour that is considered strange or bizarre. They are rewarded in the form of coloured tokens.

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Token economy (second stage)

In the second stage of the therapy, they begin to be rewarded for performing actions and behaviours that society considers "normal". Such behaviours may include making their bed and combing their hair or washing. Therefore, the schizophrenic patients are positively rewarded for their "normal" behaviour with tokens that they can later use to get privileges, such as watch a film, listen to music and getting cigarettes or even sleeping in a private room. 

The tokens are a secondary reinforcer because they do not actually provide any direct reinforcement but they can be exchanged for primary reinforcement (the privileges). Operant conditioning theory predicts that is behaviour is rewarded it is more likely to be repeated and so become "stamped in" and so the tokens aim to stamp in more appropriate behaviour. 

Operant conditioning is learning from the consequences of actions. Actions have a good outcome through positive reinforcement (reward) or nagative reinforcement will be repeated. Actions which have a bad outcome (punishment) will not be repeated. 

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Evaluation of TE Effectiveness

Allyon and Allyon (1968) reported on the use of TE with female patients with schizophrenia, who had been hospitalised for an average of 16 years. They were rewarded with plastic tokens for actions such as making their beds or combing their hair. The tokens were exchanged for pleasant activities, such as seeing a film or an additional visit to the canteen. The number of chores the patients performed each day increased from five to over forty. Thus, token economy was found to be successful in socialising the patients into taking more responsibility for themselves. The tokens provide patients with the incentive to behave in desirable ways and so can have a real effect on these negative symptoms.

Dickerson et al (2005) reviewed studies to TE through a meta analysis and beneficial effects were reported in 11 of 13 studies. They also concluded that TE was best used in combination with other therapies such as psychosocial and/or drug therapy

Paul and Lentz used token econmy for 4.5 years with institutionalised patients who had their drug therapy reduced over the same time period. They found that the patients developed social and work related skills as a result of the token economy- for example they could look after themselves. There was a reduction in their schizophrenic symptoms. After 4.5 years 98% of the patients in the token economy had been released compared to 45% of patients who recieved no treatment. Also the token economy group did much better when released into the community.

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TE Appropriateness

It could be argued that token economies are an appropriate form of treatment for schizophrenia as they are much mroe humane. This is because, in the past, schizophrenic patients in instutions could only be controlled by isolating them and confining them to their cells or rooms. The advantage, and the appropriateness of token econmy is that, by using it, schizophrenic patients in such institutions are allowed to have more freedom and independence. At the same time, the patients are being treated instead of being just locked up- which is definetly more humane and ethically appropriate. 

On the other hand, TE raises ethical issues as are the "desired behaviours" really desirable for the patient or is it more the institution that benefits? This can be countered as the improveed social behaviour of the patients such as not spitting in their food was desirable for the patients and the fellow patients. But the issue of the therapy being used as a form of social control is a serious one, many argue the treatment is patrionising and degrading. It is treating patients as children given that it is similar to star charts some parents use. Some even argue TR is dehumanising because the behavioural techniques used are more often used to train animals and so it is more a method of control than treatment.

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How informed can can consent actually be, given their condition? A number of things can limit informed consent, such as the patient many not be provided with enough information about the treatment, they may not remember the information accurately and they may just agree because they respect the therapist rather than understand the treatment. 

Token economies are also not appropriate for treating schizophrenia because, in the modern era, most patients are treated in communities and not institutions, yet token economy only really works in an institutional setting in which the therapist has tight control over the patient thus it could be said that token economy is an inappropriate form of treatment because it is outdated and because it is much less appropriate as a treatment now than it may have been in the past.

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